INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 15, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Abstinent Living at the Turning Point at Washington Women With Children Program was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to protect the confidentiality of the client ' s records.
On September 15, 2020 at 10:26 AM, clients' medication records were left unattended on a counter that was accessible to persons entering the facility and to clients entering and leaving the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The operations manager confirms that the medication records were left unattended for a brief time on a counter. The ra supervisor and the operations manager/admissions director met with the staff person who left the records unattended immediately, and stressed the importance of client confidentiality with her. It was made clear at that time that any further issues could result in termination from employment. The ra supervisors, therapists, operations manager/admissions director, and/or the project director will monitor this daily to ensure that all client confidential information is kept secure. Additionally, the operations manager/admissions director and project director have reviewed the importance of client confidentiality with all staff at the bi-weekly Solutions Meeting. All current staff is required to re-take the online DDAP confidentiality training by October 31, 2020, and submit the certificate for their personnel file. In addition, all future hires will be required to take the DDAP confidentiality training at the time of hire. This will be overseen by the operations manager/admissions director and the project director. |